Thursday, March 29, 2018

Listen: Key to leading successful transition to enterprise imaging

Paul Pierre, president of DYSIS
Paul Pierre is president and owner of DISYS Consulting an independent consulting firm that has been in business almost 25 years. Over the last 15 years, Pierre has focused primarily on Enterprise Medical Imaging. His expertise in medical imaging informatics and project management has helped healthcare clients in Canada and the US through successful major transitions in medical imaging. He started in consulting primarily in system architecture and infrastructure and focused on healthcare. He has a background in networking and infrastructure and document management. When digital imaging came along in the late 90s and early 2000s, he shifted his focus to medical imaging exclusively after that. He recently co-hosted a SIIM webinar “We’re not in Kansas anymore,” about deployment and integration of other clinical specialties into a VNA. PARCA eNews talked to him about the importance of the change-management aspects of making such a transition.

Q. In your webinar you emphasized the need for establishing working relationships and governance as being key to a successful transition to enterprise imaging. Can you elaborate a bit on that?

Everything goes hand in glove. You are starting a working relationship with people you have not really worked with before, in general. Often organizations look at enterprise imaging and they start with the radiology department because they are the ones with the most expertise. That (radiology PACS) have been going on for 20 years. There is the sense of the familiar and a common language.

Then you step outside of that and you don't have those working relationships. By nature there is no trust, no reason for trust, no real understanding of the particulars of the clinical situations. So you have to start by investing and building those relationships, and through that understanding you can develop trust and only then can you start to open up the conversations and have a dialogue.

If you come into it with preconceived notions of workflows and solutions and technologies, you are probably going to create resistance and that just becomes a barrier that is hanging over you constantly.

Q. How should PACS administrators approach the transition to enterprise imaging?
Step one is LISTEN. Ask a lot of questions about the workflow, and how they treat their patients. If you can, physically watch the flow of patients through whatever department. Visit the "customer” in their home, observe them in their natural habitat. Look for how information is transformed, what triggers people to do things and what the inputs and what the outputs are. More importantly, what else is going on around them when all of this is occurring?

Q. I imagine that in many cases the IT department makes the decision to pursue enterprise imaging and they bring in the PACS people from radiology and all the other imaging groups. How should PACS administrators approach that initial meeting?

Again that first meeting should be all about asking the departments how they work and if possible set up a visit to the department for observation. 1) that improves your information gathering, 2) it reduces miscommunications. A lot of communications occur where two people think they talking about the same things when they are not, and 3) avoid solutioning, before you understand the problem. The whole theme is don't jump to solutions because you don't know.

Q. That sounds like building the foundation for trust.

There is no difference between enterprise medical imaging and any other system. They are just systems you have to go in and understand the problem before you try to solve it. If you try to solve it with the tools you already have then you are force fitting it in. You may have to end up doing that, because at the end of the day there may be an enterprise mandate, but you will do it with understanding each other’s needs, and mutual understanding of where the trade-offs are. As the PACS administrator you are the voice of the customer to the vendor community the rest of the IT organization. So you need to understand your customer. You can let vendors do the configuration, that is fine, they understand their technology better than you probably, but you cannot abdicate understanding your customer.

Q. You emphasize the change management approach to transitioning to enterprise imaging.

Change management is always what you are doing. You are always going from state A to state B and they are going to be asked to make a lot of decisions, to agree to a lot of things.

If you put yourself in their shoes, they don't understand what they are being asked to decide, what the implications of those decisions are because they've never been through this process. So it is unreasonable and dangerous to try to get to decisions before you've gone through the process of education and understanding. I say it is dangerous because if you ask for a decision before they are comfortable making it, you're going to get yesterday's decision, or the same thing they've always done because that is where they are comfortable. That keeps your program from moving forward. You are not going to innovate and your patients are not going to get the benefit of that innovation.

If you take the time to understand their needs, and educate them on the art of the possible and let them ask as many questions as they need to ask, there is 1) a better chance you are going to get an innovative decision and 2) the decision they make they will be committed to as opposed to making a decision and revisit it later when you now have invested in the build that resulted from that decision.

If you don’t do that, the decision gets unhooked because they were asked for a decision before they were ready to make one. They made the decision and then the more they understood and thought about it, then they are coming back and changing their minds. If you want good decisions that have longevity, take the time and let people come to that. It takes a lot of time.

Q. Walk me through the planning needed for this change management component.
It is a collaborative effort. You're first meeting is ‘hi how are and what is it you do for a living?” The second is can I come and visit and observe. The third is you start to formulate ideas for solutioning, but before those ideas get too firm and fixed, discuss them with that stakeholder group. If possible get an early state prototype of what you are talking about, because you can discuss it all you like, but seeing it makes all the difference.

In that first prototype it doesn't have to be perfect. Don't waste time on what you think is right, but get enough of it that it looks somewhat reasonable and get early feedback. Silicon Valley would call this approach quick-to-fail. If you've got an idea and it is the wrong idea, get it off the table as fast as possible before you've invested too much energy. More importantly, give it enough so that the stakeholder community can then have input and buy-in and ownership of that.

The traditional approach we always take is you get a few requirements, you disappear you build it, train and go live. We go build, train, go live, and then you start getting feedback on live, which is an awful time to learn anything. You're stressed, everyone's stress level is through the roof, people are not listening they are talking, you've invested a whole ton and now you have 100s of people you have to communicate any changes to, it is a terrible place to learn.

Do your learning in a safe environment using prototyping. It is early stage feedback is what you are after. Do not, Do NOT wait to have all the ribbons and bows on your solution before getting feedback.

Q. When conducting the requirement meetings, how do you manage the expectations other disciplines might have in terms of what can and cannot be done.

Again once you understand where they are going you can have open and honest conversations about limitations. But unless you have engaged in the dialogue of understanding, you might think you understand what their expectations are but you don't know. If you've opened it up and expressed expectations, now you can cut back and say this is what we can and what we can't and what we're still working on.

Q. What are some of the common expectations you've come across in consulting?
The biggest common expectation is that somehow magically I can do nothing when I put something in and it is somehow going to work perfectly for me when I pull it back out. It is a library job. If I just throw books at a library shelf without a card catalogue and a system, I'm never going to find that book again.

2) And this is a misconception on a radiology led approach, people don't report on images outside of radiology, or don't always.

3) Other information besides the picture is more relevant than just the picture. When you speak in cardiology there are a lot more measurements and modalities of information sources than simply the picture. You need to be able to stitch all that together for appropriate presentation at the time the work is done.

4) Is the expectation that "I really need to do this anywhere. I am not stationary and in a room.” These are just different challenges. You have to cross boundaries, we have these fixed models in our minds that everything is contained within department A or B and you then you have specialists who overlay those boundaries and work with many facilities and many locations and their clear expectation is that they can serve the patient wherever the patient is and wherever they are. That is not an unreasonable expectation, but it is just harder to achieve coming from a fixed mental model of departmental radiology.

Q. How do you address those expectations?

Honesty. You say, this is my toolkit, this is what I've heard you ask for, this is the toolkit I have to work with, these are the principles upon which we agree around data quality and confidentiality. With all of those combinations, here are the solution sets we have. To get outside that solution set we need to either go for more money or go for more innovation, but we're doing this together now, we're going forward together on behalf of our patients.

If it becomes an ‘us versus them’ forget it, you are not going anywhere. All you are creating is (an environment)
 where it is, ‘IT or PACS or Radiology is trying to tell us how to work, or IT doesn't understand us.’ And whenever I hear that, that tells me there is no framework for working together. People are having two one-way conversations. 

Q. Do people call you in for consulting up front, or when they reach those kinds of impasses?

All of the above. It is just harder when there is acrimony, money has gone out the door, and time has passed. Now everyone wants to A. achieve the original result, B. for the original budget and C. for the original timeline. And you have to come in and say we thought we were on implementation but really we're just in the planning stage. That is not a comfortable message, but it is an honest message and a useful one.

I've been in situations where they thought they had laid the groundwork, but the groundwork wasn't there. It is costly to the organization because everything freezes up and you are back working through the fundamentals of relationship building and trust building and solution design.

Q. People are often a victim of what they don't know, is that the value of calling in an consultant in the beginning to get that additional perspective?

Yes, it reduces your risk. All of it is about the risks to the organization, whether it is to the PACS administrator or to the C suite, everyone has a level of risk, and if you invest early in the groundwork then you accelerate through the implementation. So it actually saves you time, reduces your risk and saves you money.

Back in the early days of software development it was always "why isn't Johnny coding?" That was the mantra. Why aren't we writing code. Well we don't understand the requirements, we don't have a plan, so I can get Johnny coding but we don't know whether what he is doing is going to be of any value. So take the time upfront, lay your groundwork and I swear to goodness you won't slow your process down, you will accelerate your implementation. It doesn't slow it down, it actually speeds it up.

Q. What is the most important advice you give people asking about how to get started at this process?

ASK the people what they do. Listen, listen, listen. Use active listening. That is fundamental to systems analysis, it is active listening.

Q. How can PACS administrators be better at that.

I've said many times in many places that if you are investing in your people, invest in their analytical skills and change management skills and less in their technical skills, because it is those skills that will allow them to transition to different technologies, different environments, different customer groups. The technology will be outdated tomorrow but those skills of listening, analysis and design and collaboration and leadership will last.

PACS administrators are often in environments where they are expecting to be told what the answers are and then they go and execute them, but when you get into enterprise you need to step up and be a leader because no one knows the answers.

Q. What is the role of PACS administrator in the enterprise imaging organization?

It definitely needs to be transitioned out of radiology into enterprise imaging organization whether that is in IT or some bridge organization and there is no right answer. Those administrators who choose to step into a leadership role excel in the new imaging informatics department, those who are what I would call order takers they have a role but it is essentially the same role, fixers of bad data and responders to pagers.

Q. What is the best thing  PACS adminsitrators can do to prepare for enterprise imaging and advance their careers?

I would say develop system analysis skills, invest in your soft skills, project leadership, systems analysis, are going to be your hightest value return.

Q. Anything else?

Follow the data, don't worry about the systems, follow the data, because it will outlive the system. So as the information is acquired and transformed, who does it, where does it happen, what is its quality. Always find out the quality of the information is at every stage of the way. Make sure you've got all of the information captured and trapped along the way. I see this all the time and the data transforms or transmits to another system but you didn't move the other two or three pieces you needed, and then you are presenting your solution and they say, well where is this, this and that? and you haven't got a solution.

The biggest challenge when entering other departments is department myopia. People see information creation, storage for their own purposes. As the enterprise imaging administrator you need to think about it for all its purposes and that is the patient's view. If you come to information design from the patient's view of that information you will get there.

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